RESUMO
OBJECTIVE: Several studies have demonstrated robust protective effects of childhood family support and cohesiveness on adult stress-related psychopathology. However, there is little evidence regarding the prospective relationship between the perceived childhood family environment and the in-theater emergence of war-zone stress-related psychological symptoms. The present report is from data collected from the Texas Combat PTSD Risk Project, which aims to identify risk and resilience factors at predeployment that predict the subsequent impact of war-zone stressors in terms of psychological symptom emergence in U.S. soldiers deployed to Iraq. METHOD: Soldiers (N = 150) completed a battery of standardized interview and self-report assessments at predeployment, including a measure of perceived childhood family cohesion. Once deployed, soldiers completed monthly web-based self-report assessments of war-zone stressors, posttraumatic stress symptoms, depression, and anxiety. RESULTS: Consistent with predictions, greater perceived childhood family cohesiveness prior to deployment robustly mitigated subsequent in-theater symptoms. However, contrary to predictions, childhood family cohesiveness did not reliably moderate the linkage between war-zone stressors and in-theater symptoms. CONCLUSIONS: Consistent with a wealth of other evidence demonstrating protective stress resilience effects of childhood family cohesion that extend across the lifespan, the present findings suggest they also extend to the war-zone environment among deployed soldiers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
RESUMO
Nurses must excel in using Artificial Intelligence (AI) - applied hospital systems, making their informatics competency crucial. ChatGPT has been trained with extensive amounts of informatics- and technology-related health data and has gained popularity. Nurses could have the opportunity to enhance their informatics competency through the knowledge generated by ChatGPT. However, its informatics competency has not been evaluated. We used the Self-Assessment of Informatics Competency Scale to measure the level of informatics competency of ChatGPT. ChatGPT fell within the range of 'somewhat competent' and 'competent,' lower than that of students in graduate programs. One subdomain, applied computer skills (clinical informatics), demonstrated competency levels close to that of students. Although the results presented certain limitations and concerns, we recognize the potential of ChatGPT to help researchers and healthcare practitioners. Nursing is advancing and continuously integrating AI technology; therefore, we should now embrace both the benefits and risks associated with ChatGPT.
Assuntos
Informática em Enfermagem , Competência Profissional , Humanos , Inteligência Artificial , Currículo , Alfabetização Digital , Avaliação EducacionalRESUMO
Background: Multiagent neoadjuvant chemotherapy (NAT) has been linked with improved survival for locally advanced (LA) or borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC). However, the existence of disparities in its utilization remains to be elucidated. Methods: All adults with PDAC were tabulated from the 2011-2017 Nationwide Cancer Database. Tumor vascular involvement was determined using the clinical T stage and CS_EXTENSION variables. The significance of temporal trends was calculated using Cuzick's non-parametric test. A Cox proportional hazard model was used to assess the impact of NAT utilization on hazard of two-year mortality. A logistic regression model was developed to determine factors associated with receipt of NAT. Results: Of 3811 patients meeting inclusion criteria, 50.8 % received NAT. NAT utilization significantly increased over the study period, from 31.7 % in 2011 to 81.1 % in 2017 (p < 0.001). NAT was associated with significantly reduced two-year mortality (Hazards Ratio 0.34, 95 % Confidence Interval [CI] 0.18-0.67).After adjustment, younger (Adjusted Odds Ratio [AOR] 0.97/year, CI 0.96-0.98) and Black (AOR 0.65, CI 0.48-0.89; ref: White) patients demonstrated reduced odds of NAT. Furthermore, patients with Medicare (AOR 0.73, CI 0.59-0.90; ref: Private) or Medicaid insurance (AOR 0.67, CI 0.46-0.97; ref: Private) had lower odds of NAT, as did those treated at non-academic institutions (Community: AOR 0.42, CI 0.35-0.52, Integrated: 0.68, CI 0.54-0.85) or in the lowest education quartile (AOR 0.52, CI 0.29-0.95; ref: Highest). Conclusions: We identified increasing utilization of NAT for BR/LA pancreatic adenocarcinoma. Despite being linked with significantly reduced two-year mortality, socioeconomic disparities affect odds of NAT.
RESUMO
INTRODUCTION: Colon cancer (CC) is the second leading cause of cancer-related deaths in the United States. Quality measures have been introduced by the American Gastroenterological Association and Commission on Cancer for optimal management of CC. In this study, we sought to identify factors that may hinder the timely diagnosis and treatment of CC at a safety-net hospital system. METHODS: Retrospective chart review was performed for patients aged ≥18 y diagnosed with CC from 2018 to 2021. Primary outcomes were time from positive fecal immunochemical test to colonoscopy, time from diagnosis to surgery, and time from diagnosis to adjuvant chemotherapy. Secondary end points were demographic characteristics associated with suboptimal outcomes in any of the above measures. RESULTS: One hundred ninety patients were diagnosed with nonmetastatic CC. The majority were Hispanic and non-English-speaking. 74.1% of patients with a positive fecal immunochemical test received a colonoscopy within 180 d. 59.6% of nonemergent cases received surgery within 60 d of diagnosis. 77% of those eligible received adjuvant chemotherapy within 120 d of diagnosis. No clinically significant demographic factor was associated with delay in colonoscopy, surgery, or adjuvant chemotherapy. Most frequent cause of delay in surgery (38.0%) was optimization of comorbidities. Most frequent cause of delay in adjuvant chemotherapy (71.4%) was delay in surgery itself. CONCLUSIONS: No clinically significant demographic factor was associated with experiencing delays in diagnostic colonoscopy, surgery, or adjuvant chemotherapy.
Assuntos
Neoplasias do Ceco , Colectomia , Transplante de Rim , Procedimentos Cirúrgicos Robóticos , Humanos , Transplante de Rim/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Colectomia/métodos , Neoplasias do Ceco/cirurgia , Neoplasias do Ceco/patologia , Masculino , Pessoa de Meia-Idade , Adenocarcinoma/cirurgiaRESUMO
INTRODUCTION: Despite the increasing use of immunotherapy in treating various cancer types, there is still limited understanding of its impact on surgical complications. We used a national database to examine the difference in surgical outcomes for rectal cancer patients who received standard neoadjuvant chemoradiation plus neoadjuvant immunotherapy and patients who received neoadjuvant chemoradiation only. METHODS: This retrospective cohort study used the National Cancer Database (NCDB). We selected patients aged 18-90 with T1-3, N1-2, and M0 rectal cancer who underwent curative-intent surgery between 2010 and 2020. We performed a 1:1 propensity match to control for patient age, sex, Charlson-Deyo comorbidity index, surgical approach, and tumor site. Our primary outcome was difference in surgical outcomes (hospital length of stay, unplanned 30-day readmission, 30-day mortality) between the two groups. Secondary outcomes included days from diagnosis to surgery and pathologic outcomes. RESULTS: Our study included 26 229 patients, of which 126 received immunotherapy in addition to chemoradiation and 26 103 received only chemoradiation. In our matched population of 125 pairs of patients, patients who received immunotherapy and chemoradiation underwent surgery later compared to patients who only received chemoradiation (median 245 vs. 144 days, p < 0.001). There were no significant differences in median length of stay (5 vs. 5 days, p = 0.202), unplanned 30-day readmission (7 vs. 9, p = 0.617), and 30-day mortality (0 vs. 1, p = 1.000) between the two groups. CONCLUSION: Neoadjuvant immunotherapy for rectal cancer is not associated with adverse surgical outcomes. This work can help clinicians optimize treatment protocols and move closer toward strategies tailored to specific patient profiles.
Assuntos
Imunoterapia , Terapia Neoadjuvante , Complicações Pós-Operatórias , Neoplasias Retais , Humanos , Neoplasias Retais/terapia , Neoplasias Retais/cirurgia , Neoplasias Retais/patologia , Neoplasias Retais/mortalidade , Feminino , Masculino , Estudos Retrospectivos , Idoso , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Imunoterapia/métodos , Adulto , Idoso de 80 Anos ou mais , Adolescente , Adulto Jovem , Seguimentos , Prognóstico , Tempo de Internação , Taxa de SobrevidaRESUMO
BACKGROUND: Contralateral prophylactic mastectomy (CPM) remains a personal decision, influenced by psychosocial factors, including cosmesis and peace of mind. Although use of CPM is disproportionately low among Black patients, the degree to which these disparities are driven by patient- vs hospital-level factors remains unknown. STUDY DESIGN: Patients undergoing mastectomy for nonmetastatic ductal or lobular breast cancer were tabulated using the National Cancer Database from 2004 to 2020. The primary endpoint was receipt of CPM. Multivariable logistic regression models were constructed with interaction terms between Black-serving hospital (BSH) status and patient race to evaluate associations with CPM. Cox proportional hazard models were used to evaluate long-term survival. RESULTS: Of 597,845 women studied, 70,911 (11.9%) were Black. After multivariable adjustment, Black race (adjusted odds ratio 0.65, 95% CI 0.64 to 0.67) and treatment at BSH (adjusted odds ratio 0.84, 95% CI 0.83 to 0.85) were independently linked to lower odds of CPM. Although predicted probability of CPM was universally lower at higher BSH, Black patients faced a steeper reduction compared with White patients. Receipt of CPM was linked to improved survival (hazard ratio [HR] 0.84, 95% CI 0.83 to 0.86), whereas Black race was associated with a greater HR of 10-year mortality (HR 1.14, 95% CI 1.12 to 1.17). CONCLUSIONS: Hospitals serving a greater proportion of Black patients are less likely to use CPM, suggestive of disparities in access to CPM at the institutional level. Further research and education are needed to characterize surgeon-specific and institutional practices in patient counseling and shared decision-making that shape disparities in access to CPM.
Assuntos
Negro ou Afro-Americano , Neoplasias da Mama , Disparidades em Assistência à Saúde , Mastectomia Profilática , Humanos , Feminino , Mastectomia Profilática/estatística & dados numéricos , Pessoa de Meia-Idade , Neoplasias da Mama/cirurgia , Neoplasias da Mama/prevenção & controle , Disparidades em Assistência à Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/etnologia , Idoso , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Estados Unidos/epidemiologia , Carcinoma Ductal de Mama/cirurgia , População Branca/estatística & dados numéricos , Carcinoma Lobular/cirurgia , Carcinoma Lobular/prevenção & controle , Carcinoma Lobular/patologia , Estudos RetrospectivosRESUMO
BACKGROUND: The role of minimally invasive surgery (MIS) in the acute management of diverticulitis remains controversial. Using a national cohort, we examined the relationship between operative approaches with acute clinical and financial outcomes. METHODS: Adults undergoing emergent colectomy for diverticulitis were tabulated from the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program. Regression models were developed to analyze the association between open and MIS approaches with major adverse events (MAE), as well as secondary endpoints. A subgroup analysis was conducted to compare outcomes between open and MIS requiring conversion to open (CTO). RESULTS: Of 9194 patients, 1580 (17.3%) underwent MIS colectomy. The proportion of MIS resection increased from 15.1% in 2015 to 19.1% in 2020 (nptrend<.001). Compared to Open, MIS patients were younger, equally likely to be female, had a lower proportion of patients with ASA class ≥3, and a higher BMI. Preoperatively, MIS patients were less frequently diagnosed with sepsis. Following adjustment with open as reference, MIS approach had reduced odds of MAE (AOR .56), ostomy creation (AOR .12), shorter postoperative length of stay (LOS; ß -1.63), and a lower likelihood of nonhome discharge (AOR .45, all P < .001). Additionally, CTO was linked to decreased likelihood of MAE (AOR .78, P = .01), ostomy creation (AOR .02, P < .001), comparable LOS (ß -.46, P = .41), and reduced odds of nonhome discharge (AOR .58, P < .001), relative to open. DISCUSSION: Compared to planned open colectomy, MIS resection was associated with improved clinical and financial outcomes, even in cases of CTO. Our findings suggest that whenever possible, MIS should be attempted first in emergent colectomy for diverticulitis. Nevertheless, future prospective studies are likely needed to further elucidate specific patient and clinical factors.
RESUMO
BACKGROUND: Acute complicated diverticulitis poses a substantial burden to individual patients and the health care system. A significant proportion of the cases necessitate emergency operations. The choice between Hartmann's procedure and primary anastomosis with diverting loop ileostomy remains controversial. METHODS: Using American College of Surgeons National Surgical Quality Improvement Program patient user file data from 2012 to 2020, patients undergoing Hartmann's procedure and primary anastomosis with diverting loop ileostomy for nonelective sigmoidectomy for complicated diverticulitis were identified. Major adverse events, 30-day mortality, perioperative complications, operative duration, reoperation, and 30-day readmissions were assessed. RESULTS: Of 16,921 cases, 6.3% underwent primary anastomosis with diverting loop ileostomy, showing a rising trend from 5.3% in 2012 to 8.4% in 2020. Primary anastomosis with diverting loop ileostomy patients, compared to Hartmann's procedure, had similar demographics and fewer severe comorbidities. Primary anastomosis with diverting loop ileostomy exhibited lower rates of major adverse events (24.6% vs 29.3%, P = .001). After risk adjustment, primary anastomosis with diverting loop ileostomy had similar risks of major adverse events and 30-day mortality compared to Hartmann's procedure. While having lower odds of respiratory (adjusted odds ratio 0.61, 95% confidence interval 0.45-0.83) and infectious (adjusted odds ratio 0.78, 95% confidence interval 0.66-0.93) complications, primary anastomosis with diverting loop ileostomy was associated with a 36-minute increment in operative duration and increased odds of 30-day readmission (adjusted odds ratio 1.30, 95% confidence interval 1.07-1.57) compared to Hartmann's procedure. CONCLUSION: Primary anastomosis with diverting loop ileostomy displayed comparable odds of major adverse events compared to Hartmann's procedure in acute complicated diverticulitis while mitigating infectious and respiratory complication risks. However, primary anastomosis with diverting loop ileostomy was associated with longer operative times and greater odds of 30-day readmission. Evolving guidelines and increasing primary anastomosis with diverting loop ileostomy use suggest a shift favoring primary anastomosis, especially in complicated diverticulitis. Future investigation of disparities in surgical approaches and patient outcomes is warranted to optimize acute diverticulitis care pathways.
Assuntos
Ileostomia , Humanos , Ileostomia/efeitos adversos , Ileostomia/métodos , Ileostomia/estatística & dados numéricos , Masculino , Feminino , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Idoso , Anastomose Cirúrgica/métodos , Anastomose Cirúrgica/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Doença Aguda , Doença Diverticular do Colo/cirurgia , Estudos Retrospectivos , Readmissão do Paciente/estatística & dados numéricosRESUMO
BACKGROUND: Although clinical outcomes of surgery for ulcerative colitis (UC) have improved in the modern biologic era, expenditures continue to increase. A contemporary cost analysis of UC operative care is lacking. The present study aimed to characterize risk factors and center-level variation in hospitalization costs after nonelective resection for UC. METHODS: All adults with UC in the 2016-2020 Nationwide Readmissions Database undergoing nonelective colectomy or rectal resection were identified. Mixed-effects models were developed to evaluate patient and hospital factors associated with costs. Random effects were estimated and used to rank hospitals by increasing risk-adjusted center-level costs. High-cost hospitals (HCHs) in the top decile of expenditure were identified, and their association with select outcomes was subsequently assessed. RESULTS: An estimated 10,280 patients met study criteria with median index hospitalization costs of $40,300 (IQR, $26,400-$65,000). Increased time to surgery was significantly associated with a +$2500 increment in costs per day. Compared with low-volume hospitals, medium- and high-volume centers demonstrated a -$5900 and -$8200 reduction in costs, respectively. Approximately 19.2% of variability in costs was attributable to interhospital differences rather than patient factors. Although mortality and readmission rates were similar, HCH status was significantly associated with increased complications (adjusted odds ratio [AOR], 1.39), length of stay (+10.1 days), and nonhome discharge (AOR, 1.78). CONCLUSION: The present work identified significant hospital-level variation in the costs of nonelective operations for UC. Further efforts to optimize time to surgery and regionalize care to higher-volume centers may improve the value of UC surgical care in the United States.
Assuntos
Colite Ulcerativa , Adulto , Humanos , Estados Unidos , Colite Ulcerativa/cirurgia , Hospitalização , Alta do Paciente , Fatores de Risco , Custos Hospitalares , Readmissão do Paciente , Estudos RetrospectivosRESUMO
INTRODUCTION: The Lower Anogenital Squamous Terminology (LAST) Project recommended unified classification for HPV-associated squamous lesions of the lower anogenital tract, using a 2-tiered nomenclature in 2013. Adherence to the new nomenclature worldwide is unknown. This study aims to assess the trend of the use of the two-tiered High Squamous Intraepithelial Lesion and Low Squamous Intraepithelial Lesion (HSIL/LSIL) as opposed to the traditional three-tiered Anal Intraepithelial Neoplasia (AIN I/II/III) classification as suggested by the LAST Project. METHODS: A literature search on full-text English language studies of premalignant anal lesion was performed on PubMed from 2002-2022. The studies were categorized by continent, and the prevalence of HSIL/LSIL classification vs AIN I/II/III was calculated. RESULTS: 546 studies and 251 studies were identified using the AIN I/II/II and the HSIL/LSIL classification respectively. Global trend suggested a statistically significant downward trend in the use of the two-tiered nomenclature system in publications globally. Regional trend including North America, Europe, and other (Asia and Latin America) showed variance in adoption of the two-tiered nomenclature system. CONCLUSION: Despite multidisciplinary collaborative effort, adherence to the recommendations to use the two-tiered system for HPV-associated premalignant anal lesions continues to be suboptimal. Further efforts are needed to identify the cause of poor adherence to be able to create strategies that reinforces unification of terminology and integration of LAST the recommendations.
RESUMO
BACKGROUND: Readmission at a non-index hospital, or care fragmentation (CF), has been previously linked to greater morbidity and resource utilization. However, a contemporary evaluation of the impact of CF on readmission outcomes following elective colectomy is lacking. We additionally sought to evaluate the role of hospital quality in mediating the effect of CF. METHODS: All records for adults undergoing elective colectomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Patients readmitted non-electively within 30 days to a non-index center comprised the CF cohort (others: Non-CF). Hierarchical mixed-effects models were constructed to ascertain risk-adjusted rates of major adverse events (MAEs, a composite of in-hospital mortality and any complication) attributable to center-level effects. Hospitals with risk-adjusted MAE rates ≥50th percentile were considered Low-Quality Hospitals (LQHs) (others: High-Quality Hospitals [HQHs]). RESULTS: Of 68,185 patients readmitted non-electively within 30 days, 8968 (13.2%) were categorized as CF. On average, CF was older, of greater comorbidity burden, and more often underwent colectomy for cancer, relative to Non-CF. Following risk adjustment, CF remained independently associated with greater likelihood of MAE (adjusted odds ratio [AOR] 1.16, 95% Confidence Interval [CI] 1.05-1.27) and per-patient expenditures (ß+$2,280, CI +$1080-3490). Further, readmission to non-index LQH was linked with significantly increased odds of MAE, following initial care at HQH (AOR 1.43, CI 1.03-1.99) and LQH (AOR 1.72, CI 1.30-2.28; Reference: Non-CF). CONCLUSIONS: Care fragmentation was associated with greater morbidity and resource utilization at readmission following elective colectomy. Further, rehospitalization at non-index LQH conferred significantly inferior outcomes. Novel efforts are needed to improve continuity of care.
RESUMO
INTRODUCTION: Despite the high recurrence rate of sigmoid volvulus, there is reluctance to perform a prophylactic colectomy in frail patients due to the operation's perceived risks. We used a nationally representative database to compare risk of recurrence in patients undergoing a prophylactic colectomy versus endoscopic detorsion alone. METHODS: We performed a retrospective cohort study using the National Readmission Database (2016-2019) including patients aged ≥18 y who had an emergent admission for sigmoid volvulus and underwent endoscopic detorsion on the day of admission. We performed a 1:1 propensity matching adjusting for patient demographics, frailty score comprising of 109 components, and hospital characteristics. Our primary outcome was readmission due to colonic volvulus and secondary outcomes included mortality, complications, length of stay (LOS), and costs during index admission and readmission. We performed a subgroup analysis in patients with Hospital Frailty Score >5. RESULTS: We included 2113 patients of which 1046 patients (49.5%) underwent a colectomy during the initial admission. In the matched population of 830 pairs, readmission due to colonic volvulus was significantly lower in patients undergoing endoscopy followed by colectomy than endoscopy alone. Patients undergoing a colectomy had higher gastric and renal complications, longer LOS, and higher costs but no difference in mortality. In the subgroup analysis of frail patients, readmission was significantly lower in patients with prophylactic colectomy with no significant difference in mortality in 439 matched patients. CONCLUSIONS: Prophylactic colectomy was associated with lower readmission, a higher rate of complications, increased LOS, and higher costs compared to sigmoid decompression alone.
Assuntos
Fragilidade , Volvo Intestinal , Humanos , Volvo Intestinal/cirurgia , Estudos Retrospectivos , Endoscopia , Colectomia , Resultado do TratamentoRESUMO
Background: Racial disparities in access to preoperative evaluation for colorectal cancer remain unclear. Emergent admission may indicate lack of access to timely care. The present work aimed to evaluate the association of admission type with race among patients undergoing colorectal cancer surgery. Methods: All adults undergoing resection for colorectal cancer in 2011-2020 National Inpatient Sample were identified. Multivariable regression models were developed to examine the association of admission type with race. Primary outcome was major adverse events (MAE), including mortality and complications. Secondary outcomes included costs and length of stay (LOS). Interaction terms between year, admission type, and race were used to analyze trends. Results: Of 722,736 patients, 67.6 % had Elective and 32.4 % Emergent admission. Black (AOR 1.38 [95 % CI 1.33-1.44]), Hispanic (1.45 [1.38-1.53]), and Asian/Pacific Islander or Native American (1.25 [1.18-1.32]) race were associated with significantly increased odds of Emergent operation relative to White. Over the study period, non-White patients consistently comprised over 5 % greater proportion of the Emergent cohort compared to Elective. Furthermore, Emergent admission was associated with 3-fold increase in mortality and complications, 5-day increment in LOS, and $10,100 increase in costs. MAE rates among Emergent patients remained greater than Elective with a widening gap over time. Non-White patients experienced significantly increased MAE regardless of admission type. Conclusion: Non-White race was associated with increased odds of emergent colorectal cancer resection. Given the persistent disparity over the past decade, systematic approaches to alleviate racial inequities in colorectal cancer screening and improve access to timely surgical treatment are warranted.
RESUMO
Purpose: Guidelines are published for referral to genetic counseling and multigene panel genetic testing for colorectal cancer. We hypothesize that these guidelines are not recognized in practice, resulting in the underreferral of patients to genetic counseling. We aimed to investigate the clinical impact of these guidelines. Methods: This was a retrospective cohort study conducted using a single academic-institution colorectal cancer patient registry. The registry included all patients ≥18 years old with a pathologic diagnosis of colon cancer, rectal cancer, or polyposis from January 2018 to January 2020 with complete chart data to determine inclusion into the genetic referral cohort. Results: Out of 225 colon cancer patients, 92 met criteria for referral to genetic testing, but only 56 patients obtained referral and 39 completed testing. For rectal cancer, 29 out of 127 patients met criteria for referral, but only 11 obtained referral and 8 completed testing. Actionable variants, defined as pathogenic or likely pathogenic, were identified in 18 colon cancer and 5 rectal cancer patients. Age made a significant difference in the referral rate for colon cancer (P = 0.02) but not rectal cancer (P > 0.05). Conclusion: Our study demonstrates poor adherence to guideline-based genetic testing. These data emphasize the need for more consistent referral to genetic testing for diagnosis of underlying inherited cancer syndromes.
RESUMO
BACKGROUND: Although early discharge after colectomy has garnered significant interest, contemporary, large-scale analyses are lacking. OBJECTIVE: The present study utilized a national cohort of patients undergoing colectomy to examine costs and readmissions following early discharge. METHODS: All adults undergoing elective colectomy for primary colon cancer were identified in the 2016-2019 Nationwide Readmissions Database. Patients with perioperative complications or prolonged length of stay (>8 days) were excluded to enhance cohort homogeneity. Patients discharged by postoperative day 3 were classified as Early, and others as Routine. Entropy balancing and multivariable regression were used to assess the risk-adjusted association of early discharge with costs and non-elective readmissions. Importantly, we compared 90-day stroke rates to examine whether our results were influenced by preferential early discharge of healthier patients. RESULTS: Of an estimated 153,996 patients, 45.5% comprised the Early cohort. Compared to Routine, the Early cohort was younger and more commonly male. Patients in the Early group more commonly underwent left-sided colectomy and laparoscopic operations. Following multivariable adjustment, expedited discharge was associated with a $4,500 reduction in costs as well as lower 30-day (adjusted odds ratio [AOR] 0.74, p<0.001) and 90-day non-elective readmissions (AOR 0.74, p<0.001). However, among those readmitted within 90 days, Early patients were more commonly readmitted for gastrointestinal conditions (45.8 vs 36.4%, p<0.001). Importantly, both cohorts had comparable 90-day stroke rates (2.2 vs 2.1%, p = 0.80). CONCLUSIONS: The present work represents the largest analysis of early discharge following colectomy for cancer and supports its relative safety and cost-effectiveness.
Assuntos
Colectomia , Neoplasias do Colo , Alta do Paciente , Adulto , Humanos , Masculino , Colectomia/efeitos adversos , Neoplasias do Colo/cirurgia , Tempo de Internação , Readmissão do Paciente , Complicações Pós-Operatórias/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Feminino , Fatores de TempoRESUMO
While mechanical thrombectomy is known to be effective for distal medium vessel occlusion (DMVO) as well as large vessel occlusion, tortuous DMVO are predisposed to vessel injury during stent retriever thrombectomy. Furthermore, getting access to the thrombus may be difficult during suction thrombectomy using a dedicated suction catheter. Most studies describe DMVO treatment using stent retrievers and dedicated suction catheters, but there are limited studies reporting DMVO treated with suction thrombectomy using a microcatheter. Herein, we describe three cases of DMVO treated with suction thrombectomy that was performed using a microcatheter and subsequently showed good results. Therefore, suction thrombectomy using a microcatheter is a viable alternative treatment for tortuous DMVO.
RESUMO
Background: Primary care physicians (PCP) play a key role in offering colorectal cancer (CRC) screenings, particularly amongst underserved populations. Given potential delays in or omission of CRC screening in the absence of a PCP, we aimed to determine stage of CRC at diagnosis in an underserved population. Methods: A retrospective chart review was conducted at two Los Angeles County safety-net hospitals. Inclusion criteria were a CRC diagnosis between 2018 and 2021 and age between 50 and 75 years at diagnosis time. The primary outcome was the cancer stage at diagnosis. Results: A total of 373 patients were included, of those, 52.5 % had a PCP. Compared to others, PCP was similar in age, racial composition, and primary spoken language (Table 1). Of patients with a PCP, 52.0% were diagnosed by screening. After screening, the most common indication for colonoscopy were blood per rectum (24.9 %) and imaging findings (18.0 %). Patients with a PCP had a significantly lower rate of late stage CRC than those without a PCP (42.4 % vs. 68.0 %, p < 0.001). After adjustment, having a PCP was associated with significantly reduced odds of late stage CRC (Adjusted Odds Ratio 0.83, 95 % Confidence Interval [0.68-1.04]). Having a PCP was not associated with any adjusted increase in number of adenomas or tumor size. Conclusions: Patients with a PCP, irrespective of undergoing screening, were diagnosed at earlier CRC stages. This underlines the crucial role of PCPs in CRC and diagnosis, reinforcing the need for their active involvement in these processes.
RESUMO
PURPOSE: Colon cancer (CC) remains a leading cause of cancer-related mortality worldwide, for which colectomy represents the standard of care. Yet, the impact of delayed resection on survival outcomes remains controversial. We assessed the association between time to surgery and 10-year survival in a national cohort of CC patients. METHODS: This retrospective cohort study identified all adults who underwent colectomy for Stage I-III CC in the 2004-2020 National Cancer Database. Those who required neoadjuvant therapy or emergent resection < 7 days from diagnosis were excluded. Patients were classified into Early (< 25 days) and Delayed (≥ 25 days) cohorts after an adjusted analysis of the relationship between time to surgery and 10-year survival. Survival at 1-, 5-, and 10-years was assessed via Kaplan-Meier analyses and Cox proportional hazard modeling, adjusting for age, sex, race, income quartile, insurance coverage, Charlson-Deyo comorbidity index, disease stage, location of tumor, receipt of adjuvant chemotherapy, as well as hospital type, location, and case volume. RESULTS: Of 165,991 patients, 84,665 (51%) were classified as Early and 81,326 (49%) Delayed. Following risk adjustment, Delayed resection was associated with similar 1-year [hazard ratio (HR) 1.01, 95% confidence interval (CI) 0.97-1.04, P = 0.72], but inferior 5- (HR 1.24, CI 1.22-1.26; P < 0.001) and 10-year survival (HR 1.22, CI 1.20-1.23; P < 0.001). Black race [adjusted odds ratio (AOR) 1.36, CI 1.31-1.41; P < 0.001], Medicaid insurance coverage (AOR 1.34, CI 1.26-1.42; P < 0.001), and care at high-volume hospitals (AOR 1.12, 95%CI 1.08-1.17; P < 0.001) were linked with greater likelihood of Delayed resection. CONCLUSIONS: Patients with CC who underwent resection ≥ 25 days following diagnosis demonstrated similar 1-year, but inferior 5- and 10-year survival, compared to those who underwent surgery within 25 days. Socioeconomic factors, including race and Medicaid insurance, were linked with greater odds of delayed resection. Efforts to balance appropriate preoperative evaluation with expedited resection are needed to optimize patient outcomes.